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Sunday, June 3, 2012

Case #7-1: Rapid Sequence Intubation (RSI) for Rookies and Reviewers

A 39M is BIBA, boarded and colored, with altered mental status. He was found down at the bottom of a flight of stairs. 130/75, 92, 14, 99%, afebrile, GCS 12 (3 Eyes, Verbal 4, Motor 5), no focal neuro deficits. He has a hematoma on his forehead. All of a sudden, during your secondary survey, he sits up in bed and becomes combative but purposeless. He's easily restrained with haldol. Now what?

I'm an intern, and have recently begun transition shifts in which I get first shot at all department intubations. In order to handle situations like the one above, I needed to be prepared.

How did I prepare?

Chris Nickson recently updated his Own the Airway! tutorial on Life in the Fast Lane. This is an amazing resource which teaches airway management by organizing free videos borrowed from other sites. The format is very user friendly.

But, the LITFL resource is missing a key element in RSI - the drugs!

Steve Carroll's straightforward and useful EM Basic podcast on airway management served as a good introduction. Before listening to the podcast, I took screenshots on my iPad of the shownotes, and pasted the pictures into a Penultimate notebook. I wrote my own notes on top of the shownotes while I listened.

To learn more about RSI drugs, I read the EM Lyceum posts on RSI pharmacology. EM Lyceum links you to the primary literature to be able to intelligently form opinions on controversial topics yourself.﻿﻿﻿﻿﻿

﻿﻿﻿﻿I realized quickly that every Web 2.o resource above referenced the clasic text, Walls' Emergency Airway Management. I ordered it from amazon, and read it cover to cover.

"The patient might have a head bleed, he needs to be intubated, but we don't want to raise his ICP," I said. We'll use a weight of about 80kgs: give him 120mg of lidocaine and 250mcg of fentanyl . Then push 25mg of etomidate, and 120mg of sux, in that order," I said confidently.

I intubated him, gave him another 50mcg of fentanyl and started him on a 2mg/min propofol drip. He was then rushed off to CT.

10 comments:

I've never understood the deal with ICP peri-intubation and if it's a real thing, or why that's could be a bad thing in head bleeds, particularly traumatic head bleeds.

Suppose you have an extra-axial bleed that's causing mass effect/exerting pressuring on the brain causing it to herniate under the falx.

The brain needs perfusion. Perfusion comes from blood flow. Flow and pressure are directly related (v=IR and the Navier Stokes equation). If extraaxial pressures are elevated and exerting effect on the brain and decreasing the cerebral pressure head, then it's totally appropriate for the brain to compensate by increasing mean cerebral pressures to raise ICP to raise cerebral perfusion.

The brain does this naturally, evidenced by the profound hypertension people with increased ICP get. Why do we assume that their increased BP is pathologic? Maybe it's a protective reflex the brain does to perfuse itself.

Regardless, my real contention is that physiology is complicated and its easy to argue either side of any point. And there's no good clinical data to make an argument either way that it's good or bad.

So why do we get all upset about theoretically raising transiently ICP for a few minutes as we perform an otherwise life-saving procedure? I have no idea.